Fill and Sign the Nonpayment Form

NOTICE OF NONPAYMENT - INDIVIDUAL TO: DATE: _____________________ Contractor _______________________________ Contractor's Address __________________________________________________________ Surety _________________________________ Surety's Address _____________________________________________________________ The undersigned notifies you that he or she has furnished _____________________________________________________________________________ (labor, services, or materials) for the improvement of the real property identified as _____________________________________________________________________________ (property description). The amount now due and unpaid is $ ___________________ . DATED on _____ day ___________________ , 20 _____ . Signature of Lienor _____ ____________________ By (signature) _________________________ Type or Print Name _____ ___________________ Address _____ _____________________________ Notice of Nonpayment Page 1 of 2 STATE OF ___________ COUNTY OF _____________ Sworn to (or affirmed) and subscribed before me this _____ day of _________________, 20______ by _________________________ (name of person making statement) who is personally known to me or produced _________________________ as identification, and who did take an oath. ____________________________ NOTARY PUBLIC Printed Name of Notary _________________________ Commission Expires _________________________ Certificate of Service I, _____________________________________, hereby certify that I have delivered this day a true and attested copy of the foregoing to ___________________________________ by: ( ) Actual Delivery to the person to be served. ( ) Mailing a true and correct copy of same by registered or certified U.S. mail, with postage prepaid, or by overnight or second-day delivery with evidence of delivery. ( ) If service cannot be made by the above methods, by posting on the premises. ________________________ Signature Notice of Nonpayment Page 2 of 2